1
PROFESSIONAL WORK: THE EMERGENCE OF
COLLABORATIVE COMMUNITY
Paul S. Adler
Dept of Management and Organization
Marshall School of Business
University of Southern California
Los Angeles, CA 90089-1421
Email: [email protected]
Seok-Woo Kwon
A. Gary Anderson Graduate School of Management
University of California at Riverside
225 Anderson Hall
Riverside, CA 92521
Email: [email protected]
Charles Heckscher
School of Management and Labor Relations
Rutgers University
New Brunswick, NJ 08981
Email: [email protected]
Version: April 21, 2007
Forthcoming in Organization Science
Acknowledgements:
Our thinking has been shaped by our research collaboration with Patricia Riley, Jordana Signer, Ben Lee
and Ram Satrasala, and from discussions with Paul Kurtin, Bill Mason, Don Berwick. Larry Prusak, Roy
Greenwood, Steve Shortell, David Smith, Martha Feldman, Jody Gittell, Phil More, Mark Kennedy,
Irving Stubbs, as well as the Senior Editor and reviewers. We thank the Packard Foundation and the
Institute for Knowledge Management (now known as the Institute for Knowledge-Based Organizations)
for generous financial support. They bear no responsibilities for the opinions expressed here.
2
PROFESSIONAL WORK: THE EMERGENCE OF
COLLABORATIVE COMMUNITY
Abstract
This paper traces the main lines of evolution of the organization of professional work. The
argument is illustrated with material on the case of doctors and hospitals. Market and hierarchy principles
have become progressively more salient in professional work; but we argue that in parallel, the
community principle has been growing more influential too. Building on Adler and Heckscher (2006), we
further argue that professional community is mutating from a Gemeinschaft, craft guild form, via
Gesellschaft forms, towards a new, “collaborative” form. This evolution, however, is a difficult one, and
the outcome is uncertain. We identify some implications for future research.
3
PROFESSIONAL WORK: THE EMERGENCE OF
COLLABORATIVE COMMUNITY
Professionals constitute an increasingly important occupational category. Historically, the
professions date back to the late medieval period, when divinity, medicine, law, and the associated
university faculty first acquired a status distinct from other occupations as “learned professions” (CarrSaunders and Wilson 1933). With the emergence of capitalism came new groups claiming professional
status: military officers, architects, scientists, and humanist scholars. In the nineteenth century, these
occupational groups actively mobilized in search of professional prerogatives, notably a monopoly over
their domain of practice. In these efforts, they were soon joined by other occupations increasingly central
to capitalist growth, such as engineering and accounting. The rise of the welfare state in the twentieth
century institutionalized teaching, social work, and public health as professions (Watkins et al. 1992).
Much of the scholarly interest in professionals has focused on their relative independence from
market and hierarchical pressures, and on the centrality of community in the organization of their work
and occupational governance. A rich tradition of research has debated whether this independence and
community are destined to erode, or whether, on the contrary, it is more likely to generalize across the
growing number of knowledge workers and expert occupations (Giddens 1991; Reed 1996; Sullivan and
Hazlet 1995). The stakes for organization theory are high: the organization of professional occupations
has been a long-standing focus of organizational research (e.g., Miner et al. 1994; Pickering and King
1995; Van Maanen and Barley 1984); professionals are key actors in knowledge-intensive organizations
(Bell 1973; Powell and Snellman 2004; Quinn et al. 1996); and they play a central role in the accelerating
generation and diffusion of innovations within and among organizations. (Scott 1995; Swan and Newell
1995). The stakes for organizing practice are high too: the welfare of contemporary society depends on
the effective organization of professional work.
The thesis of this article is double. First, the ascendance of market and hierarchy principles in the
organization of professional work has not diminished the role of community; instead, all three principles
are becoming simultaneously more salient. And second, in this process community itself is being
profoundly transformed. In developing this thesis, we review a broad range of relevant literature, reframe
key debates, and identify some issues for future research. Our primary goal is to develop a better
conceptual map of the terrain being traversed and the main directions of change; we leave for another
paper more thorough discussion of the dynamics of the change process.
We use doctors and hospitals to illustrate and to ground our argument. This choice is motivated
by the status of physicians (along with lawyers), as the most highly professionalized occupational
category, and by the status of hospitals as a locus classicus of research on professional organizations
(Flood 1995; Freidson 1963; Scott 1982; Strauss et al. 1963). Moreover, healthcare has been subject to
intensified performance pressure from both outside and within the industry (Scott et al. 2000). The
resulting tensions, while in some ways unique to health care, are surprisingly similar to those experienced
in other professions such a law (Nelson and Trubek 1992), consulting and accounting (Hinings et al.
1999), and teaching (Porter 1989; Rosenholtz 1987), and we will intersperse illustrations from these other
professions where useful.
THREE ORGANIZING PRINCIPLES
Our analysis is framed by the contrast between three coordinating principles and their
corresponding mechanisms: (a) the hierarchy principle, which relies on the authority mechanism, (b) the
market principle, which relies on price competition, and (c) the community principle, which relies on trust
4
— see Exhibit 1. (Some authors replace community with “networks” in this tripartite structure: networks,
however, seems to us less precise, because markets and hierarchies are also tie networks.)
[put Exhibit 1 about here]
The three organizing principles have different strengths and weaknesses. Hierarchy’s comparative
advantage is control; market’s is flexibility; community’s is trust and knowledge growth (Adler 2001;
Dore 1983; Eccles and White 1988; Ouchi 1980; Powell 1990). The hierarchy principle is effective in
disseminating codified knowledge; but it offers only weak incentives to create new knowledge and it does
not handle well tacit knowledge’s embeddedness in practice (Lave and Wenger 1991). The market
principle creates strong incentives to create knowledge, but only under strong appropriability regimes,
and such regimes impede the socially optimal dissemination of knowledge (Arrow and Hurwicz 1997;
Arrow 1962). Community is thus typically prominent in collectivities — like professions, universities,
and corporate R&D units — where knowledge creation and diffusion are critical.i Community’s main
weakness is the risk of closure and insularity (Freidson 1970).
We use this three-dimensional representation to reframe two key debates surrounding
professionals. First, as we will argue below, professionals increasingly work in organizations rather than
in solo practices, and these organizations increasingly take a hierarchical form and have come under
increasing market pressure; these trends have provoked considerable debate over the emerging
organizational form of professional work. One line of thought assumes that the three organizing principles
we have identified are mutually exclusive “ideal types,” and that therefore the rise of market and
hierarchy must mean the demise of community. We follow an alternative line of thought in arguing that
the three principles are better understood more abstractly, and that in real institutions they typically
coexist. The ascendancy of market and hierarchy has not meant the retreat of community: the community
principle appears to be growing in salience alongside the other two principles.
Second, there is considerable debate over the meaning of community when market and hierarchy
become so influential. We argue that this changing constellation leads to a profound mutation in the form
of community. Using Tönnies (1957) classic distinction, we argue that professional community has long
embodied a mix of the features of Gemeinschaft-like, craft guilds on the one hand and Gesellschaft-like
individualistic associations on the other. The emerging forms of professional organization suggest that a
transition is under way towards a form of community that transcends the Gemeinschaft/Gesellschaft
antinomy, a “collaborative” form (building on Adler and Heckscher 2006).
In the following sections, we first lay some foundations, then present these two steps in our
argument. We then discuss the dynamics of change and why the emergence of this new form of
professional organization is so difficult and uncertain. We conclude with some implications for future
research.
COMMUNITY, DOMINANT
The distinctiveness of professionals’ work has been characterized in terms of three main sets of
attributes: non-routine tasks requiring expertise based on both abstract knowledge and practical
apprenticeship; occupational monopoly over activity with this practice jurisdiction and individual
autonomy within it; and legal and ethical responsibility for this practice that is typically reflected in
values of service.ii There has been considerable disagreement on the direction of causal ties among these
three sets of attributes (for a masterful review, see Freidson 2001); however for the purposes of the
present essay, what is striking is the extent of agreement: the three sets of attributes all point to the
centrality of the community principle in the organization and experience of professional work.
Professional tasks and expertise requirements make community a particularly efficient organizational
principle, as argued in the previous section (e.g. Parsons 1968b). Professionals rely on a collegial
community structure to mobilize power in asserting their jurisdiction over such tasks and in governing
themselves in the performance of these tasks (e.g., Barber 1963; Freidson 1992; Starr 1982; Waters
1989). Values constitute the normative dimension of the professional community and are a key
5
mechanism for assuring its capacity to guide their work and govern themselves (Barber 1963; Hall 1968;
Parsons 1968a).
Occupations differ in the relative salience of the community principle, and to this extent in their
degree of professionalization. Reed (1996) distinguishes three broad categories among the moreprofessionalized occupations: independent professions (doctors, architects, lawyers), organizational
professions (managers, salaried engineers, technicians, teachers), and “knowledge workers” who function
as experts-for-hire (consultants, project engineers, computer analysts). He notes that coordination among
the first group relies primarily on collegial relations; the second group relies more on hierarchy; and the
third group relies more on a network of market relations. The second and third of these groups encounter
difficulties in asserting the claims to professional status precisely to the extent that community is a less
influential principle in organizing their work.
Some scholars attribute considerable efficacy and virtue to professionals’ reliance on the
community principle. A strong version of this view sees professional community as a form of
organization overlooked by Weber. Spencer (1970), Satow (1975), and Rothschild-Witt (1979) point out
that whereas three of the four types of social action and associated normative bases identified by Weber
(affectual, traditional, purposive-rational) were associated with corresponding forms of authority and
administration (respectively: charismatic, traditional, and rational-legal), Weber identified no form of
authority corresponding to the fourth type of social action, value-rational. According to Weber, valuerationality (Wertrationalität) provides an underpinning of legitimacy for a social order “by virtue of a
rational belief in that order’s absolute value, thus lending it the validity of an absolute and final
commitment” (Weber 1957). Satow (1975) and Sciulli (1986) argue that professions are characterized by
a normative commitment to values (e.g., health, scientific progress) that transcend organizational
imperatives; that these normative commitments have enabled professions — relatively large collectivities
— to govern themselves; and that their collegial form of governance might therefore plausibly be
interpreted as exemplifying Weber’s “missing type.”
Other Weberian scholars are less sanguine about professional community (e.g. Waters 1989). If
value-rationality did not figure in Weber’s typology of forms of organization, it is because valuerationality affords only an unreliable foundation for the legitimate domination (authority) required of any
robust form of administration. Effective administration requires that subordinates accept the legitimacy of
orders from authorized superiors; but value-rationality accords no legitimacy to orders, since each
member is assumed equal in their exclusive subservience to the “absolute value” to which they are all
devoted. Weber thus saw collegial community as effective only within small organizations and within the
small group at the peak of large organizations (Noble and Pym 1970). Skeptics such as Waters (1989)
refer to the critical accounts of the medical profession offered by Starr (1982) and Freidson (1975) to
argue that the collegial form of governance does not appear to have allowed professions to steer their
members towards policies that privilege broader social interests when these latter conflict with members’
narrow self-interests.
As discussed in the following sections, the professions have, over the past few decades, come
under increasing performance and accountability pressure. Whatever judgment we might formulate
concerning the performance of the professions in the past, these mounting pressures pose a serious
challenge to the professions’ traditional value-rational, community-based form of organization. As a
result, new patterns are emerging in the organization of professional work.
MARKET AND HIERARCHY, ASCENDENT
An accumulating body of evidence shows that over the past few decades and across a broad range
of more and less professionalized occupations, market and hierarchy pressures have been mounting
(Leicht and Fennell 1997). These pressures are external, coming from clients, courts, and regulators (Scott
et al. 2000); they are internal, due to competition from other practitioners (Gaynor and Haas-Wilson.
1999); and they are inter-professional, as categories jostle over jurisdictions (Bechky 2003; Halpern 1992;
Zetka 2001).
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As a result of these combined pressures, a growing proportion of formerly independent
professionals are working in large corporations, as salaried employees or partners; if they are partners, the
old collegial norms of governance are increasingly giving way to hierarchical forms; and across the board,
the “ethic of service” is being displaced by a commercial spirit (Brint 1994; Robinson 1999). Whatever
protection of the public interest that had been afforded by professional governance in the past is rapidly
eroding (Nanda 2003). Looking into the future, the liberal professions seem doomed to a fate similar to
the craft guilds.
Certainly the tendencies in the legal profession in the USA today suggest as much (Kritzer 1999).
The traditional legal partnership is under attack; to protect themselves from personal liability, partnerships
are being reorganized as professional corporations and limited liability partnerships. To deal with the
growing scale of the mega-law firms, partnerships are being restructured to create tiers of non-equity
partners and to centralize more authority in the hands of CEO-style managing partners and executive
committees (Crain 2004). A growing proportion of lawyers work in large firms, where they are
increasingly subject to hierarchical norms of productivity, revenue-generation, and quality (Galanter
1983; Spar 1997; Wallace 1995). Barnhizer (2004) argues that legal profession has lost all capacity for
self-governance, and should therefore be regulated like other forms of commerce.
Accounting too is under attack. Big corporate clients appear to have captured their auditors
(Suddaby et al. 2005). Big accounting firms are diversifying into multi-disciplinary practices, and in the
process, losing the ability to socialize young professionals into any distinctively professional, as distinct
from commercial, norms and ethics (Toffler 2003). Suddaby et al. (2005) argue that the
internationalization of accounting firms’ practice has ruptured the regulative bargain between the state
and this profession, and that on the global plane, there is no agency capable of representing any interests
other than those of the large corporate clients in the negotiations over international regulation.
Medicine too is mutating. Physician-owned facilities multiply, turning physicians into capitalist
investors (Hackbarth 2005). In areas heavily populated by HMOs, the traditional fee-for-service model is
now less common than capitation or nonproductivity-based salary (Robinson 1999). A growing number
of hospitals no longer function on the traditional Medical Staff model but instead employ physicians
directly and/or contract with medical groups (Casalino 2003; Robinson 1999); and in both cases,
hierarchical and market pressures come to bear on physicians far more powerfully. A growing category of
physician-managers blur the boundaries between bureaucratic authority and professional relations (on
clinical directors in the U.K., see Ashburner and Fitzgerald 1996; Bloomfield 1992; Cohen 2000; Doolin
2002; Fitzgerald 2000; on the U.S., see Hoff 1999). Traditional professional values of autonomy are being
challenged by the demands for collaboration in bureaucratically structured service delivery and collective
process improvement (Audet et al. 2005; Lohr 1995; Panush 1995).
Trends such as these accelerated in the latter decades of the previous century, and these trends
have fueled an animated debate over the extent to which professionalism and its distinctive reliance on the
value-rationality of professional community is compatible with advanced capitalism and its characteristic
emphasis on the formal rationality embodied in both markets and hierarchy (Ritzer and Walczak 1988). In
this debate, several broad positions can be discerned (on the corresponding positions in debates on the
evolution of medicine, see Hafferty and Light 1995; Hafferty and Wolinsky 1991; Light and Levine 1988;
Light 1993; Special issue 1988; Wolinsky 1993). First, with Bell (1973), some advance a
professionalization thesis according to which professions will gradually supersede corporations as the
dominant organizing principle in society — a view whose antecedents go back to Durkheim (1997/84).
Second, against the professionalization thesis, some observers highlight the shift from the more
autonomous form towards the more heteronomous form of professional organization (using Scott’s 1965
distinction). Some (e.g. Haug 1973; Pfadenhauer 2006; Rothman 1984) interpret this as
deprofessionalization, attributing the trend to exacerbated rivalry between professions, diffusion of
expertise, and rising levels of public education and skepticism. Others (e.g. Derber et al. 1990; McKinlay
and Stoeckle 1988) advance a proletarianization interpretation that highlights professionals’ progressive
subordination to hierarchical and market rationality. Finally, there are those who see the central vector of
7
change not in the displacement of community, but rather in its mutation. Freidson (1984), for example,
argues that there is little empirical support for the idea that professionalism’s distinctive features have
eroded, but much evidence that regulation within professions has become more rationalized and
formalized (see also Wallace 1995).
We submit that the professionalization, deprofessionalization, and proletarianization theses all
miss key considerations. The professionalization account understates the growing power of market and
hierarchy relative to community in capitalist society. Conversely however, the deprofessionalization and
proletarianization accounts miss the factors within a capitalist society that constantly reproduce and
indeed magnify the need for the knowledge-creating power of professional community. Capitalist
development is increasingly knowledge-intensive, and as discussed above effective knowledge-work
needs community. Knowledge-workers need community within which to learn the craft elements of their
skill-sets and within which they can continually advance and share knowledge, both theoretical and
practical (Lave and Wenger 1991). The forces of capitalist competition themselves simultaneously tend
both to destroy and to recreate community (Adler 2001).
Moreover, with the exception of mutation theory, the contending theories are vitiated by their
common assumption that professionals would cease to be true professionals if their governance ceased
being exclusively under the community principle and if market and/or hierarchy principles were to come
into play. Krause (1996) states this assumption baldly: “Visualize a triangle, with the state, capitalism,
and the professions at the corners.” His analysis is that the professions are losing out to a combination of
state and capitalist forces. Savage (1994; 2004) makes a similar assumption in arguing the opposite thesis:
seeing markets, hierarchies, and “networks” as mutually exclusive forms of organization, she argues that
the technical uncertainty of medical professionals’ work explains and ensures the persistence of the liberal
professional model over corporatized forms of practice. Puxty et al. (1987) draw a triangle whose apexes
are Market, State, and Community, and locate forms of professional regulation within this space. We
argue that such analyses fall prey to a fallacy of misplaced concreteness: they treat their three components
as mutually exclusive ideal types, and as a result they truncate the space of possible combinations by
making it impossible to imagine that two or three of the elements could be simultaneously at work in
structuring concrete collectivities such as professions (for similar argument, see Eccles and White 1988;
Ouchi 1980; Powell 1990).iii They assume that the strengthening of one principle must imply the
weakening of at least one of the others, forgetting that the overall degree of organization of a collectivity
is itself variable.
In practice, it is precisely such combined forms that seem to be proliferating (see e.g. Brock et al.
1999). Thus, while the archetypical form of organization of professional work — the independent liberal
profession and the small-scale professional partnership — is slowly disappearing, the new forms often
reflect greater salience of all three principles. Consider the portraits of the traditional professional
partnership and emerging “managed professional business” (MPB) form offered by Cooper et al. (1996).
The professional partnership’s interpretive scheme, systems, and structure all reflect the community
principle. The MPB introduces the market and hierarchy principle in all three domains: its interpretive
scheme redefines client service in market terms as value for money, and introduces concerns for
hierarchical rationalization and effective management; its systems introduce tight accountability for
specific market and finance targets and more centralized hierarchical decision-making; its structure
introduces more market alignment of specialized skills and subunits and more hierarchical integration
devices. At the same time, however, community is preserved and even strengthened in the MPB. It is
preserved because the managing partner and executive committee are still elected and their policy
direction is therefore subject to collective control. And community is strengthened because the MPB’s
more complex compensation systems now reward partners for mentoring and practice development
activities that were ignored under the “eat what you kill” norms of the traditional professional partnership.
These mutations are visible in the evolution described in the various cases in Brock et al. (1999): studies
of accounting, consulting, health care, and law all show a shift from the traditional “professional
partnership” model to a “managed professional business” model that is distinctive in its combination of
8
all three organizing principles (see also Hargreaves 1994 on schools; Pinnington and Morris 2002 on
architecture; Wallace 1995 on law firms).
Even as the independence of the liberal professionals recedes, community appears to be
strengthening among both the remaining liberal professionals as well as across the other types of
relatively professional occupations. Perhaps the most visible manifestation of this is the growing interest
in “communities of practice” (Davenport and Prusak 1998; O'Dell et al. 1998). This trend surely has an
element of faddishness; we submit, however, that it also reflects a real need in the modern capitalist world
for stronger mechanisms by which knowledge-workers can maintain and develop their working
knowledge. Both within and across firms and not-for-profit organizations, there is considerable
institutional innovation underway to create fora and networks — communities — that can support this
need. A growing number of firms are bringing engineers, scientists, and other experts together, within and
across their traditional “functional” groups, to share information about innovations and practice-based
insights. Agencies such as the World Bank, the Army, and the Navy have been investing considerable
resources in facilitating the emergence and work of communities of practice (Snyder and Briggs 2003).
Similarly, among consulting firms and other experts-for-hire, collaboration in such cross-cutting
communities is increasingly seen as a valuable as fostering greater knowledge-sharing (Adler 2006;
Davenport and Prusak 2005; Fulmer 2001; Leonard and Kiron 2002; Wenger et al. 2002; Wenger and
Snyder 2000).
In healthcare and law, even as the traditional liberal professional model recedes, the popularity of
such communities of practice has grown. Accountability pressures for greater efficiency and quality call
for more systematic innovation that is more closely grounded in daily practice (Frankford et al. 2000).
Medicine has long relied on upstream, off-line R&D in universities or the medical device and
pharmaceutical industries; but pressures for cost-effectiveness, safety, and quality have stimulated the
emergence of community-based performance-improvement practices that engage the rank-and-file
practitioner (Audet et al. 2005; Swan et al. 2002). Similarly, in law firms, there is growing interest in
creating internal communities and knowledge management infrastructure for sharing working knowledge
(Lamb and Davidson 2000).
COMMUNITY, TRANSFORMED
The previous section argued that the new emerging form of organization of professional work
combined rather than replaced community with market and hierarchy. We are, however, still left with the
question of the meaning of community in this new constellation. It is not at all clear what community
means when the pressures of market and hierarchy are so strong.
The problem is posed most starkly for the liberal professions, because for many observers the
liberal professions embody community in its purest form. As Gordon and Simon (1992) observe, the
collegiality of a small partnership of autonomous professionals doing intrinsically meaningful work
stands as a prefigurative model of a utopia of a “free association of producers”; from this vantage point,
the adoption by liberal professions of corporate forms represents a further extension of Weber’s iron cage.
It certainly feels that way to many physicians and lawyers who bemoan the corporatization and
bureaucratization of their professions.
This section contests the assumption that the liberal profession is the highest expression of
community. For this argument to proceed, we need a typology of forms of community. We build on Adler
and Heckscher (2006), who contrast the two traditional forms of community -- Gemeinschaft and
Gesellschaft as described by Tonnies (1957) – with a new, “collaborative” form. iv They argue that the two
traditional forms are limited in their ability to support the development and diffusion of knowledge, and
that as a result, functional pressures are encouraging the emergence of the collaborative form. Their
analysis did not, however, address the specific forms of community in professional work. In the following
paragraphs, we argue that important forces are indeed pushing professional community in the direction of
a more collaborative form. If the liberal professions are doomed, it is not because the rise of hierarchy and
9
market threatens community: it is because they embody a form of community that is increasingly
obsolete.
Gemeinschaft and Gesellschaft in professional organization
Krause (1996) characterizes the liberal professions as “guilds”: this is half correct. The medieval
craft guilds were largely Gemeinschaft-type collectivities, and some semi-professional occupations today
still resemble closely these guilds (e.g. real-estate agents, screen actors); but the modern liberal
professions embody a mix of Gemeinschaft and Gesellshaft forms of community (as noted by Parson,
1939). As such, the liberal professions are somewhat more effective knowledge-ecologies than were the
guilds — but perhaps not effective enough to deal with the pressures on them.
On the one hand, the liberal professions embody some elements of Gemeinschaft that were
prominent in the medieval guilds. Like guilds, the liberal professions are characterized by occupational
closure and monopolistic competition. Like the guilds too, the practitioners of the liberal professions
employ only a limited number of workers. The lawyer may employ “associates”; but as with the guilds,
these are limited in number, since they are apprentices who require the lawyer’s direct supervision. An
individual doctor may employ some office assistants and technicians; but as with the guild workshops
these assistants serve only to enhance the doctor’s own task performance, not as a direct source of profit.
On the other hand, the modern liberal professions also evidence some Gesellschaft characteristics
(Mellow 2005). Where the craft guilds remained very small-scale operations, modern law firms and
medical groups, adapting to the exigencies of the market, have grown enormously in scale and have
introduced rational administration — although, like guilds, their authority structures remain relatively flat.
Whereas craft guilds relied on tradition-based apprenticeships, the liberal professions rely on rational
university training — although this is combined with apprenticeships as “resident” doctors and
“associate” lawyers, etc. As Parsons (1939) pointed out, modern liberal professionals are universalistic in
their orientation compared to the particularism of the guild craftsmen’s world; they are more functionally
specific and demonstrate greater affective neutrality — although, like the guilds, they preserve something
of Gemeinschaft’s collective orientation. Gesellschaft is even more influential in the organizational
professions and experts-for-hire categories: here the guild elements of professionalism have been largely
eradicated by the corrosive effects of formal rationality, market, and hierarchy.
These various mixes of Gemeinschaft and Gesellshaft forms of community are limited in their
capacity to develop and diffuse knowledge: the Gemeinschaft bond is too insular and traditionalistic
(Waters 1989), and the Gesellschaft bond is too narrowly self-interested (Sharma 1997). Craft guilds were
not entirely technological conservative (see Epstein 1998; against the received wisdom summarized by
Mokyr 2002); but they offered little support for the development of new technology because they had no
differentiated research functions; and they offered little support for the diffusion of new technologies
because this diffusion relied on the migration of skilled practitioners. In contrast, the modern professions,
based in universities, are equipped with a specialized knowledge-creation capacity; but this capacity is far
removed from the problems of daily professional practice (Sternberg and Horvath 1999); and when this
distance is combined with strong professional autonomy, the result is predictable: even when
professionals are obliged to regularly update their technical know-how in continuing professional
education classes, there are scandalously large lags and unwarranted variations in professional practice.
Medicine illustrates the problem (on the parallel problems of law firms, see Maister 2006).
Quality assurance in medicine was long dominated by a philosophy akin to manufacturing’s “minimum
acceptable quality” approach -- long after large swaths of manufacturing had adopting continuous
improvement practices (Buetow and Roland 1999). And Continuing Medical Education is notoriously
ineffective in disseminating new technologies and practices (Oxman et al. 1995). The profession’s
inability to ensure appropriate quality levels and diffusion rates has increasingly been challenged by a
growing public demand for accountability (Emanuel and Emanuel 1996). It is, after all, these deficiencies
that explain why avoidable medical errors in the U.S. healthcare delivery system kill the equivalent of
“two 747s crashing every three days” (Leape 1994).
10
These deficiencies are in considerably measure a reflection of nature of medicine’s professional
community. Consider the community formed by doctors at a hospital. Most doctors are not employees of
the hospital, but independent professionals who are afforded “privileges” to practice there (Perrow 1965).
The doctors collectively govern themselves and their relation to the hospital administration through the
leaders they elect and the committees they form in a formally constituted Medical Staff. This structure
might in principle support a vibrant community of practice dedicated to continuous improvement; but in
many cases, it has supported parochial egoism. Decisions by the Credentials committee to refuse or
revoke privileges are sometimes simply anti-competitive and self-interested (Blum 1991). It was not until
recently that doctors applying for privileges were even required to reveal prior disciplinary or legal
actions against them. Peer reviews by the Quality committee are sometimes muted because the income of
staff members depends on a referral stream from the subject of the review (Baldwin et al. 1999). White’s
(1997) characterization of what he calls the “traditional Joint Commission [JCAHO] model” of the
Medical Staff is sadly eloquent in this regard.v Department committees often function as a club for mutual
protection and advancement. Because leadership is voluntary and rotating, there is often no long-range
planning “other than to try to preserve the status quo” (White 1997 p. 306). There is often an entrenched
aversion to resource management and outcomes measurement systems since they threaten individual
autonomy (Freeman et al. 1999; Wynia et al. 2000). There is little loyalty to the staff as a whole. The
participatory, one-person-one-vote approach gives equal power to members who may practice in the
hospital only rarely, and these members often block any changes that they see as threatening in any way.
Committees accumulate in response to JCAHO requirements or internal needs, but are rarely reviewed for
effectiveness.
The Emergence of Collaborative Community
While there are important countervailing forces (which we discuss below), the demands on
contemporary professional work for greater accountability and for more effective knowledge generation
and diffusion are stimulating the emergence of a new form of community, one that transcends the
limitations of the craft guild and the liberal profession. This appears to be the common thread running
through some of the most striking innovations in the organization of professional work.
Adler and Heckscher (2006) have argued that some such transformation of the nature of
community is operative across a broad range of relatively knowledge-intensive occupations and
organizations. They argue that community/market/hierarchy framework we have used in this paper needs
extension because community itself can take qualitatively different forms, and a new form is emerging
that they call “collaborative.” This new form contrasts with the two earlier ones in several ways — see
Exhibit 2.
[put Exhibit 2 about here]
Collaborative community is distinctive, first, in its social structures that support horizontal
coordination of interdependent work processes. In contrast, Gemeinschaft relies on what Durkheim
(1997/84) called a “mechanical” division of labor — “pooled” in J.D. Thompson’s (1967) terminology —
where coordination relies on traditional norms. Gesellschaft’s division of labor is “organic” —
interdependent — but relies on market prices and hierarchical authority to ensure coordination.
Collaborative community, like hierarchy, supports interdependence with formal procedures; but whereas
under the hierarchy principle, these procedures are defined by hierarchical superiors and used by them to
monitor performance and drive improvement, under collaborative community, the procedures are
designed collaboratively and used by peers to monitor each other and to work together to improve
performance. Compared to other forms of community, collaborative community is distinctive in its
reliance on value-rationality – its participants coordinate their activity through the shared commitment to
a set of ultimate goals: they form a “community of purpose” (Heckscher 1995). Its highest value is
therefore interdependent contribution to these shared goals. In contrast, Gemeinschaft values loyalty and
Gemeinschaft values rational consistency, individual integrity, and autonomy. Subjectively, collaborative
community is distinctive in its reliance on interdependent self-construals: rather than the dependent self-
11
construals characteristic of traditional Gemeinschaft or the independent self-construals characteristic of
modern Gesellschaft.vi
When viewed through the lens of this typology, it becomes clearer why the community of the
liberal professions is seen a prefigurative (Gordon and Simon 1992): in at least one key respect,
professions already embody the collaborative form, namely, in the central role played by valuerationality. In other respects, however, as argued in the preceding paragraphs, Gemeinschaft and
Gesellschaft prevail. Our thesis here is that the emerging type of professional community more fully
embodies the collaborative form.
We should note, however, one caveat. The collaborative model as characterized by Adler and
Heckscher and summarized in Exhibit 2 understates a key feature of challenge currently facing
professional work: the discussion above makes clear that the collaboration demanded of professionals
today is not restricted to peer professionals, but increasingly embraces peers from other professions
(surgeons, for example, need to develop more comprehensive collaboration with anesthesiologists), with
lower-status colleagues (with nurses), with clients (patients), with administrators (hospitals management),
with organized stakeholders (patient rights groups), and with regulators (government). Collaboration
circumscribed by Gemeinschaft insularity will not satisfy the demands currently weighing on the
professions. A more outward-looking, “civic” kind of professionalism seems to be on the agenda: this
would embody more fully the collaborative ideal (see Hargreaves 2000; Sullivan 2005).
Exhibit 3 expands on the key features of this new, collaborative and civic, form of organization of
professional work, using medicine to illustrate. The following paragraphs elaborate.
[put Exhibit 3 about here]
In contrast to the traditional model of the Medical Staff described by White above, consider the
portrait painted by the Institute of Medicine of “a new health system for the 21st century” (Institute of
Medicine 2001). Where the traditional care delivery model is one in which “Individual physicians craft
solutions for individual patients” (p. 124), in the model advocated by the IOM:
“The delivery of services is coordinated across practices, settings, and patient conditions over time.
Information technology is used as the basic building block for making systems work, tracking
performance, and increasing learning. Practices use measures and information about outcomes and
information technology to continually refine advanced engineering principles and to improve their
care processes. The health workforce is used efficiently and flexibly to implement change” (p. 125).
The IOM report describes an evolution path from the guild-like form of medical practice beyond
the liberal profession form towards a collaborative form. Collaborative learning is the heart of the new
model. Its procedures support a focus on patient service; utilization management is a responsibility shared
by all physicians; information systems support both individual physician decision-making and collective
discussion of individual performance differences; strong leaders develop relationships of trust and
communicate a vision (Maccoby 1999). Healthcare organizations such as Intermountain Health Care and
the Mayo Clinic exemplify aspects of the emerging model, although neither of them appear to have
implemented all its features (Bohmer et al. 2002; Maccoby 2006; Maccoby 1999). Robinson (1999)
describes the mutation underway in these terms:
“The now passing guild of autonomous physician practices and informal referral networks offered
only a cost-increasing form of service competition and impeded clinical cooperation among
fragmented community caregivers. The joining of physicians in medical groups, either multispecialty
clinics or IPAs, opens possibilities for informal consultation, evidence-based accountability, and a
new professional culture of peer review” (p. 234)
The leitmotif of the new form of professionalism is “collaborative interdependence” (see e.g.
Silversin and Kornacki 2000a; Silversin and Kornacki 2000b). A growing number of hospitals are
drawing physicians into collaboration with nurses and other hospital staff to improve cost-effectiveness
and quality, often bringing together previously siloed departments in the process (Gittell et al. 2000). Bate
12
(2000) describes the new form of organization that emerged at one NHS hospital as a “network
community,” characterized by constructive diversity rather than unity, by transdisciplinary forms of
working rather than tribalism. A recent report describes the creation at Riverside Methodist hospital in
Ohio of “clinical operating councils” that brought cross-functional and cross-status groups together to
examine improvement opportunities in broad “service lines” such as primary care, heart, women’s health
(Hagen 2005). Other hospitals have found that such committees are the ideal vehicle for developing and
tracking the implementation of clinical pathways (Adler et al. 2003; Gittell 2002). Here, guidelines are
not imposed on physicians by insurance companies aiming ruthlessly to cut cost; instead, they are
developed collaboratively by teams of doctors, nurses, technical and administrative staff, aiming
simultaneously to improve quality and reduce cost. In these new structures, physicians are drawn out of
their fiefdoms and beyond their “captain of my ship” identity. Intermountain Health Care (Bohmer et al.
2002) and San Diego Children’s Hospital (March 2003) exemplify such collaborative approaches to
pathway development. These two cases are also notable for the important role played in each by staff
functions that facilitate efforts to generate practice-based knowledge. Where Freidson (1984) feared that
such staff functions would fragment the profession and erode the autonomy of the practitioner, the
experience of hospitals such as these that have been most successful in implementing guidelines/pathways
suggests that strong staff/line collaboration is a crucial success factor (Kwon 2005; Tucker and
Edmondson 2003).
Some of the larger medical groups too have been developing new organizational forms to support
the collaborative learning needed in the new competitive environment. Governing boards are evolving
away from simple partnership meetings towards more complex, articulated structures capable of
exercising effective leadership (Epstein et al. 2004). At groups as different as the Mayo Group and
Permanente Medical Group, an explicit ethic of collaborative interdependence has emerged (Olsen 2001;
Pitts 2003). New organizational structures and processes link previously autonomous physicians and
departments in improvement efforts (Gittell et al. 2000; Norton et al. 2002). The corporate form appears
to facilitate these changes. “Best practices” such as disease management programs, quality-oriented
practice pattern information, and financial bonuses for quality are far more common in large, integrated
medical groups such as Permanente than in the “cottage industry” of private practitioners in small offices
(Rittenhouse et al. 2004).
Beyond the individual hospital, communities of practice are increasingly being used in lieu of
conventional Continuing Medical Education to accelerate learning and diffusion (Endsley et al. 2005;
Frankford et al. 2000; Parboosingh 2002). “Quality improvement collaboratives” have attracted
considerable attention as a way to bring together a broader community around specific improvement goals
(for an overview Massound et al. 2006; for example Mills and Weeks 2004). The most ambitious of these
bring together a variety of stakeholders from different hospitals, medical groups, health plans, and
employers to learn from each other (Solberg 2005).
Alongside these cases in healthcare, other professions also provide examples of collaborative
community. Numerous professional service firms are working towards what Maister (1985) called the
“one-firm firm” (see also McKenna and Maister 2002 for an update.). Here, the emphasis is on teamwork
rather than the “eat what you kill” ethos of the Gesellschaft partnership that still prevails in the vast
majority of U.S. law firms (Poll 2003). As Cooper et al. (1996, p. 631) note:
“The meaning of the term ‘partner’ has also changed. In the MPB, a partner is a team player, one who
trusts the leadership and works for the common good, for example by transferring work to the person
in the firm who is most competent or short of work.”
A growing number of professional firms in law and accounting are now seeking performance
improvement through collaborative community approaches to “practice management” (Lambreth 2005;
Lambreth and Yanuklis 2001; Yanuklis 2005). Some in-house legal departments are using participative
approaches to Six Sigma (Sager and Winkelman 2001).
13
Teaching is another illuminating case. According to Hargreaves (1994; 2000), teaching once
relied on a craft-type community. Beginning in the 1960s, teaching moved into the “age of the
autonomous professional”: this brought greater status, more technical knowledge, and higher salaries; but
professional autonomy also inhibited innovation by impeding the diffusion of superior practices. By the
1990s, a new age had begun, that of the “collegial professional,” and in the current period the sphere of
collaboration is broadening, drawing teachers into more active involvement in the wider community (see
also Nixon et al. 1997).
TOWARDS COLLABORATIVE PROFESSIONALISM?
We should not underestimate the difficulties facing the propagation of this new form of
professional organization. The ethos and structures of autonomy among the liberal professions create a
powerful counterweight to any move towards the broader and denser interdependencies characteristic of
collaborative community. Robinson (1999) dissects the multiple economic, legal/regulatory, and
organizational impediments that slow the emergence of larger medical groups and other forms of
“corporate” — i.e. organized — medical practice. Leape and Berwick (2005) analyze the multiple factors
that explain why progress on quality in medicine has been so slow in recent years, and highlight the role
of the “culture of medicine” and its “tenacious commitment to individual, professional autonomy” as a
“daunting barrier to creating the habits and beliefs ... that a safe culture requires.” Indeed, even when the
appropriate formal structures are in place, the new models face deep resistance:
“Many physicians, however, are individualistic in orientation and do not necessarily enter group
arrangements very easily or comfortably. …[B]uilding physician groups is a difficult process. Most
of the groups visited [in this study] are not well organized — they are groups in name only. Whatever
group culture does exist is often oriented to preserving this loose-knit affiliation rather than
developing a stronger organization. This culture of ‘autonomy,’ however, is not conducive to building
an organization that encourages the development of physician-system integration or care management
practices” (Gillies et al. 2001).
Cooper et al. (1996) delineate the complex dynamics of change in the presence of sedimented
organizational archetypes and active resistance. The professional categories whose market and political
positions are most entrenched – such as specialist doctors – can mount formidable opposition to the forces
of change. This resistance gains strength from professionals who feel that the attack on the liberal
profession model is an attack on the quality of professional service (Fielding 1990; Hoff and McCaffrey
1996; Warren and Weitz 1999). And their concerns are not without foundation. Managed care companies
attempt to influence treatment decisions through denials of payment authorization, and drug formularies
restrict the range of medications physicians can prescribe (Himmelstein et al. 2001; Warren et al. 1998).
A wave of hospital conversions to for-profit status have increased profits, but also led to reduced staffing
and salary rates and to increased mortality rates (Picone et al. 2002). Resistance by physicians and public
revulsion at some of the denials of treatment imposed by insurance companies seem recently to have
slowed down the trend to capitation of fees and corporatization of organization that had accelerated
during the 1985-2000 period (Cunningham 2004).
Moreover, the emergence of collaborative community in professional work has not yet shown the
way to a new form of regulative bargain for liberal professions. In the case of medicine, notwithstanding
the unfolding crisis of healthcare costs, the American Medical Association has been resolutely opposed to
any regulatory changes that might involve cost containment (e.g., Council on Ethical and Judicial Affairs
1995). The American Institute of Certified Public Accountants (AICPA) resisted pressure for several
years from the Securities and Exchange Commission to separate accounting and consulting and to tighten
oversight to ensure the independence of auditors. It was only after the Enron scandal that Congress acted
via the Sarbanes-Oxley Act to subordinate the AICPA to an independent board, the Public Company
Accounting Oversight Board (US Securities and Exchange Commission 2003).
Some professionals, however, have taken a more proactive stance towards the new accountability
demands. Berwick and his colleagues at the Institute of Healthcare Improvement orchestrate several
14
programs that aim to radically improve healthcare through collaborations between physicians, hospital
executives, patients, employers and other stakeholder (see www.ihi.org). Sachs (2003) argues for an
“activist” teaching profession (see also Nixon et al. 1997); Nixon et al. (1997) describe its key elements
in terms consistent with our model: collegiality, negotiation, collaboration, and partnership, and they
emphasize the interdependence of teachers with students, community, and other professions and agencies.
Peters et al. (1999) argue for a “more publicly engaged professional practice” of science. These struggles
within professions are not new (see on law, Halliday and Karpik 1997; Shamir 1995); but they appear to
have taken on new urgency in the face of the mounting challenges to the more traditional forms of
professional community.
Among the organizational and expert-for-hire professions, collaborative community appears to be
making more headway (see e.g. Adler 2006 on the case of software services consulting). In these
occupations, the counterweight of entrenched autonomy is reduced by previously established hierarchical
and market structures and by the direct pressures for improved performance. (On the other hand, these
same features give instrumental market rationality greater weight relative to value-rationality, and this
limits the development of a properly civic ethos.) We lack reliable data on the ecology of these various
organizational forms; but our review of the main books and case collections suggests that examples of
“communities of practice” are disproportionately more common within corporations and bureaucratic
agencies than among the liberal professions. It is often examples from the former sectors that are used as
templates in efforts to legitimize the new form among liberal professions (see for example Bate and
Robert 2002; Institute of Medicine 2000, 2001).
CONCLUSION
Within the liberal professions as well as across the broader spectrum of relatively
professionalized occupations, external and internal pressures for greater accountability, quality
improvement, and cost reduction are intensifying. Neither hierarchy nor market alone affords very
effective responses to these pressures. Hierarchy creates vertical authority structures which are ineffectual
in supporting rapid knowledge growth. The market principle, while popular in the current wave of “neoliberalism,” is ineffectual because the “market for reputation” fails in the presence of deep asymmetries of
expertise in professional-client relationship. From the social welfare economics point of view, the fact
that this expertise asymmetry has been somewhat reduced by higher education levels and increasing client
sophistication suggests not that market or hierarchy should replace professional governance, but rather
that clients should play a more active role in this professional governance -- considerably more active
than was allowed by the earlier forms of professional community which left professionals almost entirely
autonomous, regulated and accountable only from a distance.
Our analysis suggests that a new form of community may indeed be taking shape in the
organization of professional work in response to these pressures. This analysis suggests some directions
for future research at both the organizational and the individual levels. At the organizational level, the
Adler-Heckscher characterization of forms of community and our extension to the professions in this
essay needs more scrutiny, both from a theoretical and an empirical point of view. The theoretical
argument needs testing: for example, a strong implication of our analysis is that communities of practice
in knowledge-intensive contexts will be more effective when they take a collaborative as distinct from
Gemeinschaft or Gesellschaft form. A key step will be to operationalize the distinctions so they can be
unambiguously deployed in empirical research. Research instruments designed to capture the salience of
community controls need to be sensitive to the different “textures” of Gemeinschaft, Gesellschaft, and
collaborative forms. Exhibits 2 and 3 suggest that several dimensions along which differences in structure
could be captured: the nature of the division of labor, the nature of interdependencies, and the structure of
the tie network. It would be particularly useful to test whether the proposed collaborative form took a
similar shape in the liberal professions and in the organizational and expert-for-hire categories.
Our paper has not devoted much space to the individual’s subjective experience of these different
forms of professional work; but if our analysis captures real organizational differences, we should expect
15
to find corresponding differences in professional self-identities. In the collaborative form, we expect to
see more inter-professional cooperation, as professionals learn to work in more heterogeneous teams and
learn to see other professional communities and non-professionals as sources of learning and support
rather than interference. Research to date has focused mainly on the barriers, status tensions, and
jurisdiction disputes that impede collaboration; future research could usefully focus on how more
collaborative forms give rise to new identities. A related question is how to prepare new professionals by
training and socialization to participate in this new form.
However, we do not want to overstate our case. The move towards a form of professionalism
based on collaborative community is a difficult one, and the outcome is far from certain. It is not
inconceivable that under the pressures of hierarchy and market forces, the professions’ commitment to
value-rationality be further eroded, that the trust nexus be displaced by the cash nexus, and that the
quality of professional services progressively degrade. However, the alternative scenario we have
sketched also seems possible, where professions abandon the insular, elitist model, and embrace greater
interdependence with a broader range of stakeholders. Many professionals would experience this move as
a stressful destruction of their traditional independence (e.g., Swan et al. 2002); but, as Marx noted,
history often progresses by its bad side (Marx 1976/1847: 174).
16
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26
EXHIBIT 1: COMMUNITY, HIERARCHY, AND MARKET AS THREE
ORGANIZING PRINCIPLES
(Adapting Adler 2001; and Cardona et al. 2004)
COMMUNITY
HIERARCHY
MARKET
Social mechanism:
Trust
Authority
Price competition
Control exercised over:
Inputs
Process/behavior
Outputs
Fits tasks that are:
Interdependent
Dependent
Independent
Best supports goals of:
Innovation
Control
Flexibility
What is exchanged?
Favors, gifts, know-how
Obedience to authority for
material and spiritual
security
Goods and services for
money or barter
Are terms of exchange
specific or diffuse?
Diffuse
(A favor I do for you
today is made in
exchange for a favor
and at time yet to be
determined. Reciprocity
is generalized rather
than specific.)
Diffuse
(Employment contracts
typically do not specify all
duties of employee, only
that employee will obey
orders. Other hierarchical
relations imply a similar
up-front commitment to
obeying orders or laws,
even those yet to be
determined.)
Specific
Are terms of exchange
made explicit?
Tacit
(A favor for you today
is made in the tacit
understanding that it
will be returned
someday somehow.)
Explicit
(The employment contract
is explicit in its terms and
conditions even if it is not
specific. Ditto for other
kinds of hierarchical
relation.)
Explicit
27
EXHIBIT 2: THREE FORMS OF COMMUNITY
(Adapted from Adler and Heckscher, 2006)
Structure
Values
GEMEINSCHAFT
GESELLSCHAFT
COLLABORATIVE
Division of labor
(using
Durkheim’s 1997
categories)
* “Mechanical”
division of labor
coordinated by
common norms
* “Organic”
division of labor
coordinated by price
and/or authority
* Growth in organic
division of labor
coordinated by
conscious
collaboration
Nature of
interdependencies
* Vertical
dependence
* Horizontal
independence
* Collaborative
interdependence, both
horizontal and vertical
Tie network
structure
* Local, closed
* Global, open
* More global, open
ties, as well as
stronger local ties
Basis of trust
* Loyalty
* Honor
* Duty
* Status deference
* Integrity
* Competence
*
Conscientiousness
* Integrity
* Contribution
* Concern
* Honesty
* Collegiality
Basis of
legitimate
authority
* Tradition or
charisma
* Rational-legal
justification
* Value-rationality
Values
* Collectivism
* Consistent rational
individualism
* Simultaneously high
collectivism and
individualism
Orientation to
others
* Particularism
* Universalism
* Simultaneously high
particularism and
universalism
Orientation to self
* Dependent selfconstruals
* Independent selfconstruals
* Interdependent selfconstruals
28
EXHIBIT 3: THREE FORMS OF PROFESSIONAL COMMUNITY: THE
CASE OF MEDICINE
(Based on Institute of Medicine (2001); Maccoby (1999); other references in text.)
Task
expertise
Structure
Medicine as a craft
guild
Medicine as a liberal
profession
Medicine as a collaborative and
civic profession
* tacit knowledge
* mix of tacit and explicit
knowledge
* expertise acquired in university
training plus apprenticeship plus
actively managed continual
learning both on and off the job
* expertise acquired
in apprenticeship
Division of
labor
Nature of
interdependenci
es
* expertise acquired in
university training plus
apprenticeship, with
limited continuingeducation “updates” and
journal reading
* mechanical
division of labor
coordinated by
common norms:
every practitioner is
a generalist
* organic division of
labor between generalists
and specialists:
coordinated by referrals
and dyadic social
exchange
* earnings based on
individual patient
fees
* organic division of
labor between
practitioners and
specialized university and
corporate researchers:
coordinated by market
and social ties
* vertical
dependence of
patient on doctor
and of apprentice on
doctor
* horizontal
independence of
doctors from each
other
* practitioners need new skills:
team-work, learning, information
systems, managerial
* more extensive specialization of
practitioners
* organic division of labor
coordinated by conscious
collaboration: Medical
Groups/Staffs ensure planful
collaboration between primary care
and specialists and among
specialists
* emergence of new professionalmanagerial roles
* earnings based on
patient fees plus profit
sharing among partners
* salaried doctors rewarded both
for individual and group
performance, both costeffectiveness and quality, both
clinical work and organizational
roles, both patient care and
community health
* vertical dependence of
patient on doctor
* collaborative interdependence of
doctor and client
* entrants to profession
undergo both rationalized
formal training and craft
type apprenticeship
* collaborative interdependence
within professional organization:
Medical Group/Staff has formal,
participative structures and
enabling procedures for managing
workflows and for reviewing
quality and utilization; Group/Staff
leadership plays key role
* horizontal
independence of doctors
from each other
* limited size of
practice: one doctor
can supervise only
few apprentices
* limited size of practice:
few economies of scale
and little role for
leadership
* direct democracy
in governance of
guild
* direct democracy
among medical group
partners and Medical
Staff members
* autocratic relation
to apprentices
* faster rate of growth in technical
knowledge
* strong economies of scale in
management infrastructure
* representative democracy among
partners allows for high levels of
consistency and coordination plus
high levels of participation
* legitimate participation extends
to lower-status collaborators (e.g.
nurses) and to external
stakeholders
29
Structure of tie
network
Values
Basis of trust
* local, closed:
doctors have little
communication with
any others outside
their locale
* greater opening towards
world of science during
university training,
occasional continuing
education, and journals
* doctors also linked to global
databases of best-practices
* deference of
patient to doctor
* deference of patient to
doctor
* transparency to peers and
patients
* deference of
apprentice to master
* deference of apprentice
to master
* honor amongst
masters
* profession assures
minimum level of
competence by review of
exceptional incidents
* professional colleagues regularly
review each other’s costeffectiveness and quality to
identify and disseminate best
practices
* reliance by peers and
clients on personal
integrity of professional
Basis of
legitimate
authority
* stronger ties to broader range of
actors in the local community
* records are open to patients and
peers
* external stakeholders engage
regular dialogue with professionals
about cost and quality
* authority of master
based on mastery of
traditional knowhow
* professionals are
independent of
hierarchical authority
Values
* technical prowess
and commercial
success
* technical prowess and
commercial success
* contribution as part of an
interdependent effort on behalf of
patients
Orientation to
others
* collectivism in
loyalty to guild
* collectivism in loyalty
to the profession: no
public criticism of
colleagues
* transcends tension between
collectivism and individualism in
ethos of collaborative
interdependence
* plus expectation of
consistent rational
individualism in pursuit
of personal gain
* simultaneously high
particularism and universalism:
doctors responsible for both
individual patient and community
health
* plus individualism
in pursuing personal
interests within
collective norms
* particularism in
commitment to
individual patients
and personal
practice patterns
* value-rational authority based on
validity of evidence: evidencebased medicine
* in theory, the legitimacy
of “orders is based on
value-rationality; in
practice, based on formal
credentials and reputation
for expertise
* tension between
collectivism and
individualism managed
by monopolistic
competition
* universalism (in
principle) in commitment
to science combined with
particularism (in practice)
in commitment to practice
patterns based on
personal experience
Orientation to
self
* belonging: guild
membership plus
private property
* autonomy plus
collegiality
* interdependent collaboration;
teamwork
30
ENDNOTES
i
Differentiating input, behavior, and output controls within organizations leads to a similar
conclusion (Abernethy and Brownell 1997; see review by Chenhall 2003; Eisenhardt 1985; Ouchi 1978;
Snell 1992; Thompson 1967). Input controls (selecting staff for values compatibility and ensuring strong
socialization) imply reliance on community; behavior controls are classically bureaucratic-hierarchical
mechanisms; and output controls resemble the market’s reliance on price/quantity assessments. Input
controls are relied upon when there is incomplete knowledge of cause/effect relations and ambiguous
performance standards -- which are precisely the conditions that prevail in highly professionalized,
knowledge-intensive tasks.
ii
We should note that this characterization is largely restricted to the situation in the U.K. and
U.S.A. (Freidson 1994). In continental Europe, government’s role was stronger and more direct in
shaping the structures and values of professions: a higher proportion of professionals are employed by the
state; many are educated at prestigious, state-controlled institutions of higher education; and it is with
these institutions rather than a corporate professional body that they identify. The viability of this weaker
form of professionalism has led European scholars to see more compatibility between bureaucracy and
professionalism than is commonly asserted in Anglo-American research. It has also occasioned an ongoing debate about the historical-sociological significance of the profession as a construct (see for
example Sciulli 2005). In the present essay, we leave aside these concerns to focus on the AngloAmerican constellation.
iii
Our argument is similar to that of Snell (1992), Cardinal, Sitkin, and Long (2004), Roth, Sitkin,
and House (1994), Kirsch (1997), and Jaworski (1988): they focus within organizations and contrast
informal and formal control systems, and show that these can be combined within the one organization.
Their informal controls resemble what we have called community, and the formal controls are a mix of
hierarchy and market.
iv
Where many commentators interpret Tönnies’ Gemeinschaft/Gesellschaft contrast as one
between community and its absence in anonymous market transactions, we follow Adler and Heckscher
(2006) in arguing that Gesellschaft too is a form of community, one based on shared values of consistent,
instrumentally-rational, self-interested, action: these values constitute crucial background conditions for
market and modern bureaucracy in their real instantiations. Gemeinschaft, by contrast, is a more
traditional form of community based on strong personal bonds of loyalty and values of honor and shame.
v
The Joint Commission on Accreditation of Healthcare Organizations evaluates and
accredits nearly 15,000 health care organizations and programs in the United States. Formed in 1951, it is
an independent, not-for-profit organization. Among the criteria for accreditation, hospitals must show an
effectively functioning Medical Staff structure.
vi
This concept of collaborative community is quite different from that of “network sociality”
(Wittel 2001) and related concepts that celebrate the proliferation of weaker ties supported by information
technology and broader social trends such as globalization. Most of the accounts of such network
communities suggest more than anything the further development of classical Gesellschaft. In some cases,
of course, even on-line communities also develop Gemeinschaft and collaborative qualities (e.g. De
Cindio et al. 2003).